There are multiple theories about how the ongoing COVID-19 pandemic began; but what no one seems to know exactly is how it will end. An earlier coronavirus, SARS-CoV, had most of the victims developing severe symptoms and virus transmission happening after the onset of symptoms; and this helped in its containment. Traditional infection control measures were sufficient to control the spread. However, with SARS-CoV-2, a huge majority of the victims would not even know that they have a disease, and asymptomatic patients become the major spreaders. This makes the virus stealthy, and very dangerous to the high-risk populations, ironically because it is not too dangerous to the general population.
We are still in the initial phase of this global pandemic. That being said, the world is still struggling to understand why its spread and devastation until now has been less than anticipated in many of the populous countries of the world. Out of the ten most populated countries of the world, only two (the USA and Russia) have confirmed cases per million population that is greater than the world average. When it comes to deaths per million population, nine out of ten most populous countries have an average lesser than the global average.
The current pandemic will possibly end with a combination of several containment measures that buy time, new medicines to treat symptoms, and development of herd immunity through a likely vaccine or through infection itself. In the case of COVID-19, India as a nation has the relative advantage of a low proportion of people with high-risk non-communicable diseases and a low proportion of elderly. But with very high population density India has to prevent the virus from reaching these vulnerable populations through a systematic approach. We also have additional disadvantages of very weak hospital systems, undernutrition, and high environmental pollution, which may all have possible influence on the outcomes of this respiratory virus infection.
The endgame is nowhere in sight. Unless the virus chooses to disappear on its own, we are probably looking at a period of 12-18 months, or even longer. There are three possible ways in which COVID can become a manageable risk.
- Development of new treatment options for severe cases
- Development of a new vaccine
- A certain threshold of population (anywhere between 50%-70%) achieving herd immunity through infection
In a large country like India no blanket policy will do exactly what it is supposed to do. But an early lockdown is a very expensive weapon that we used after a lot of thought. It has surely bought us time, but we have also lost time within lockdown, which could have been used much better mapping the spread of the virus using wider testing. The health ministry operates under severe constraints stemming from the very little money that we invest as a country in health. However, this is just part of the problem. From the beginning, the ministry has been admittedly trying to allay fear and panic, often at the cost of not offering evidence-based solutions. Be it the painfully slow expansion of testing, or the effort to protect our health workers with the untested hydroxychloroquine, or the inability to procure PPEs (personal protective equipment) in time, there are many examples.
We do not know about the true extent of direct impacts of the disease per se on the Indian population yet, barring a few cities and states where the spread has been quick with high human cost. Across India, the real impact has been on regular healthcare delivery, which has got dirupted, and many fear a high human cost due to healthcare access being curtailed for non-COVID health conditions. The repercussions of the economic lockdown has been harsh, and since severe cases and deaths have been relatively low, it will become more and more difficult, politically, to continue with strict measures. Ensuring voluntary compliance to physical distancing measures, and protecting the high risk populations seem to be the available way forward for India in the medium run.
However, as the country readies a slow journey back to a new normal, we need to get the framing of the discussion right: it need not be on lifting the COVID-19 lockdown, but should be on the modalities of extending it in specific geographies. Right now, India is dividing its 755 districts into green, orange and red zones, and planning to bring green and orange zones slowly back to normal, one step at a time. The main challenge, as of now, will be to keep deaths at a low level as the virus spreads in a controlled manner without triggering panic. This means protecting the high-risk populations as economic activity is restored bit by bit. It will entail making sure that green zones are indeed green by deploying testing strategies, ensuring voluntary compliance of physical distancing measures, and by building necessary infrastructure where needed for reverse quarantine.
It is clear that India’s preparations as well as inventory, in contrast to the needs that we may face in the coming days, from what the examples of other countries indicate, look extremely modest.. The existing social reality also limits the effectiveness of even the limited healthcare infrastructure that we have. The health worker-patient relationship is dominated by conflict and often, violence. Other than perhaps for a small number of rockstar doctors in a few cities who cater to the political elite, a medical career in India is a very risky one. The stories of shortages of PPE leading to health workers getting infected, and health workers getting attacked by infuriated patients and relatives etc. are all familiar stories within the Indian health system, and a pandemic emergency has just made them more visible and stark.
The realization that India cannot afford to take the fight to the hospitals perhaps resulted in the early lockdown. Chronic low spending in public hospitals lead to shortages of staff, medicines and equipment. It affects quality of care, and patients are outraged by delays and what is perceived as ‘negligence’, often leading to violence against hospital staff. This in turn, leads to defensive practice, where almost every serious case is referred to a tertiary care facility, losing precious time and lives, thus perpetuating the spiral. It is a lose-lose situation, resulting from paucity of investments that the health sector deserves. One hopes that COVID-19 serves as a wake-up call for the political elite, and amendments are made soon.
Near and Medium-term Measures
There needs to be three non-negotiables within the healthcare system during the medium term to fight and minimize damage done by COVID-19. Firstly, the chances of hospital-acquired infections will have to be brought down to as near zero as possible. Currently, many hospitals are acting as hubs of infection, putting their staff and patients at risk. Secondly, it needs to be ensured that COVID-19 does not cause denial of hospital services for non-COVID health conditions. In enhancing readiness for a disease that has not yet started a full frontal attack, the system should not deny care for people with existing health conditions who need it the most. In restarting health services, extreme care must be given to ensure the previous point. Lastly, disruption of immunization as well as vertical disease programmes should be remedied at the earliest, to avoid preventable deaths in the future, and also to keep as many inpatient facilities free for a possible onslaught by COVID-19.
In addition, as green zones slowly get out of lockdown and agricultural and manufacturing activity resumes, the hospital as well as the community surveillance system will have to be on a high alert constantly. For those areas without sufficient healthcare facilities, options like mobile railway hospitals will have to be kept on reserve, in case outbreaks happen eventually. The Indian Railways has reportedly built many such hospital wards on wheels. Each carriage available is sanitized and converted into a hospital ward, to be able to accommodate up to 16 patients, complete with a nurses’ station, a doctor’s cabin and enough space for medical supplies and equipment. Each train can be sent to locations with rising cases of coronavirus if the need arises.
Ensuring supply of affordable medicines will be another challenge. Given the overdependence on China for bulk drugs and the disruption of certain supply channels, alternative arrangements may have to be made and PMBJP (Pradhan Mantri Bhartiya Jan Aushadhi Pariyojana) outlets need to be leveraged to ensure that essential medicines are available in ample supply.
The Union Ministry of Health is currently working with partners to establish an “Interfaith Corona Coalition” to engage religious communities in action against COVID-19. Given the polarized situation in many regions, such measures can potentially save many lives, and should be strengthened and mainstreamed.
Long-term Measures
According to a mapping analysis done by NITI Aayog, in the present 3-Tier structured level of care being provided by public health facilities, the District Hospital (DH) serves at the secondary referral level. Its objective is to provide comprehensive secondary health care services to the people in the district at an acceptable level of quality and to be responsive and sensitive to the needs of people and referring centres. There are 734 DHs across India providing crucial services to the population, and only 201 have 300 or above beds. There is a need to increase the bed capacity in most districts.
India needs to make the most of the impact of this pandemic on global supply chains and diversify its sources of raw materials and basket as well as destinations for products. This is a good time to end the dependency for bulk drugs or APIs (active pharmaceutical ingredients) on China by either emerging as a major manufacturer or facilitating partnerships with countries and help them develop local capacity.
As we navigate a future where physical distancing will be the norm for the next 12-18 months, India needs to leverage telemedicine in a big way to leapfrog existing and emerging challenges. India has recently released a set of telemedicine guidelines, which can guide this process, but this is an opportunity that cannot be missed. Remote solutions for consultation as well as diagnostics should be aggressively explored.
AADHAAR’s use as a unique health ID is an idea whose time may have come. With privacy concerns addressed, AADHAAR has the capacity transform Indian health sector fundamentally. As India gets out of lockdown and domestic migratory movements resume, issues like portability of health insurance coverage will come to the fore. AADHAAR can be the fulcrum around which India’s new universalist social protection system revolves. Pumping in fresh resources into the health sector is a non-negotiable. With 90% workers in the informal sector, social protection systems will have to be ramped up considerably, and perhaps this is a good time to make the Pradhan Mantri Jan Arogya Yojana (PMJAY) universal. It is already available for free to more than half of the population, and can be expanded to the non-poor on a premium payment basis. Perhaps it can be made free for a year or two for the whole population, while we struggle with the virus Added to this is the challenge of making potable water available across the country.
The huge and expanding network of Health and Wellness Centres (HWCs) within the Ayushman Bharat programme should become centres of health promotion as well as prevention-related activities. These should also have a key role as the hub of community surveillance, as well as the gatekeeper of PMJAY. Furthermore, India’s disease reporting framework needs to be expanded and strengthened tremendously and the private sector that caters to two-thirds of the population needs to be brought into the surveillance system with a more active role.
Disclaimer: The views expressed in this article are personal.
Oommen C. Kurian leads the health initiative at the Observer Research Foundation, a think-tank based in New Delhi.
